The Subtalar Joint, or, Everything You Never Wanted To Know About Where It Hurts

Ah, yes, the Subtalar Joint. Used to hang out there all the time, toss back a few pints, kick it with the hommies, play a little snooker. But then, it got too weird, ended up having to pay through the nose for a cheap laugh. Er, I mean, its that part of the foot of every clubbie that is usually the site of the worse pain. Looky here:


See this link!

So, the subtalar joint is the interface between your heel bone - the calcaneus, and the bone that sits on top of the calcaneus, called the talus. The talus is the bone that serves as the mortise of your ankle joint. The subtalar joint is the only joint in the body that moves through all three cardinal body planes, and thus imparts "tri-plane motion." This triplane motion is what permits the leg, and thus the entire body above, to rotate internally and externally against the foot while the foot is "pinned" to the ground. Without this ability, your other joints above the subtalar joint have to try and provide this same rotational component to your gait, which, most sadly, they cannot do. Its not that they don't want to - I'm sure even if you asked them nicely, they would have to hand their heads and tell you how sorry they are that they cannot aid you in your request. Its just that they are not "designed" to provide this kind of motion. Tsk.

So why do clubbies often have so much pain in this area? Two reasons, really. One is that due to our various surgeries and castings, we have a much narrower range of motion in our subtalar than does a normal subtalar joint. As we get older, this inadequate amount of motion begins to wear away at the cartilage of the joint, causing osteoarthritic changes, which increases inter-joint inflammation. And Voila! Pain.

Second reason - Due to those same surgeries, the various ligaments holding the subtalar together are compromised. Remember - they had to stretch one side (medial) and sometimes release (cut) some of those ligaments to get your foot/feet back into the so-called normal position. If you think about it, it means there was already damage done, even if for good reasons. Trauma cares nothing for motives - trauma is what it is.

This is why many doctors think a fusion is called for, because by stopping all joint motion, well, that joint stops hurting. Which of course is true, but... Remember what I said up there near the top? That this joint is the ONLY joint that provides this critical motion? And if you take away or limit that motion, then other joints will have to "take up the slack?" Except - there ain't no slack. What this means is that sooner or later (and mostly sooner) you have to look at a probable ankle fusion, then a knee fusion, and then, well, by then, your doctor is dreaming of giving you a voice fusion, ya dig? Essentially, you are trading one locus of pain for another. Just so you know.

This is why properly made foot orthosis and rocker soles can often slow the overall deterioration of the subtalar joint, by limiting the NEED for the joint to some degree, while permitting the gait to function closer to normal, while maintaining the subtalar joint as close to its "neutral" position as possible. This simply means to have the joint not at the end of its range of motion all the time. This can often allow you many more years of relative comfort. I say relative, because it is not a perfect solution. Its merely the lesser of two evils, in many instances.

I have had some short-term success having steroid injections in the subtalar joint, but I wouldn't recommend it for the faint of heart, or for the timid. It hurts. Like the blue freakin' blazes, let me tell you. They have to stick the needle quite a ways in there, and then the fluid has to push everything out of the way, and oh, criminy. Just one word of advise if you are planning on doing this - leave the gun at home. It's not considered polite to shoot the doctor.

I have noticed, over the years, that I get temporary relief by stretching and holding the foot back in the clubbed direction. Ironic, right? But this is one of the few ways to open the subtalar joint. Remember - the subtalar is at the end of its range of motion when the foot is maximally pronated, which is the case for most of us clubbies. By stretching the foot in a supinatory direction, you take the foot away from the end range, thereby temporarily relieving the constant pressure that causes the pain.

Of course, hot soaks, paraffin baths, hydrotherapy, hot tub jets, even ultrasound all can offer some temporary relief. But the goal should be to do whatever you can to get those puppies off their fully pronated thrones. So to speak.

We will be talking about this issue more in the coming months, hopefully with a couple of guest columns. Till then, try to stay out of the Fusion Bar and the Subtalar Joints. ya gotta cut back on the night life sooner or later. It is sure to catch up with you - ya ain't no spring chicken any more, right?